Tag Archives: Public Health

Sprawl, Health, and creating better cities through Smart Growth

Urban Sprawl and Public HealthPart 2 on Urban Sprawl and Public Health looks at potential interventions and theories that can help reduce the impact of sprawl (read part 1 here). For authors Howard Frumkin, Lawrence Frank, and Richard Jackson, hope lies in the new strategies being put forth under the terms Smart Growth and New Urbanism, arguing for Smart Growth at least as a public health strategy. I have a lot of issues with New Urbanism and Smart Growth as they are so often removed from issues of equity and spatial justice, but it’s interesting to think of how to rebuild and rework our cities as part of a plan around improving health.

They trace a lineage of people working on the connections between health and cities — Dr. John Henry Rauch (1828-1894) in Chicago arguing for land use policies to improve public health, cemeteries at a remove from dense neighborhoods being one of them. Frederick Law Olmstead, and garden cities. Edwin Chadwick working sanitary regulations, housing standards, public water and sewage systems in the UK, Thomas McKeown at Birmingham, who

showed that many of the health advances of the nineteenth and twentieth centuries resulted not from better medical care, but from ‘upstream’ improvements such as better urban infrastructure–better housing, neighborhoods, water, food, and transport. (203)

They also name psychiatrist Leonard Duhl, who has looked at connecting mental health with urban design and community involvement. His ideas have been broadened by physician Trevor Hancock. In 1987, the World Health Organization jumped on the bandwagon, initiating a Healthy Cities Network, which I confess I had never heard of.

There are of course many who could be added to this list, and in the UK at least you have the Marmot Review among others, trying to move health care providers to think more broadly about wellness and how it connects to social and environmental factors.

So…to return to the strategies they promote, we start with Smart Growth. The Environmental Protection Agency itself formed the Smart Growth Network in 1996 together with a number of other nonprofits and governmental organizations. The Networks’ ten Smart growth principles (the whole document ‘Getting to Smart Growth: 100 Policies for Implementation’ can be found here):

1. Mix land uses
2. Take advantage of compact building design
3. Create a range of housing opportunities and choices
4. Create walkable neighborhoods
5. Foster distinctive, attractive communities with a strong sense of place
6. Preserve open space, farmland, natural beauty, and critical environmental areas
7. Strengthen and direct development towards existing communities
8. Provide a variety of transportation choices
9. Make development decisions predictable, fair and cost effective
10. Encourage community and stakeholder collaboration in development decisions

The book goes on to give a more elaborate set of principles in full…they’re interesting, so I do the same — the full text can be found here:

Community principles

  1. All planning should be in the form of complete and integrated communities containing housing, shops, work places, schools, parks and civic facilities essential to the daily life of the residents.

  2. Community size should be designed so that housing, jobs, daily needs and other activities are within easy walking distance of each other.

  3. As many activities as possible should be located within easy walking distance of transit stops.

  4. A community should contain a diversity of housing types to enable citizens from a wide range of economic levels and age groups to live within its boundaries.

  5. Businesses within the community should provide a range of job types for the community’s residents.

  6. The location and character of the community should be consistent with a larger transit network.

  7. The community should have a center focus that combines commercial, civic, cultural and recreational uses.

  8. The community should contain an ample supply of specialized open space in the form of squares, greens and parks whose frequent use is encouraged through placement and design.

  9. Public spaces should be designed to encourage the attention and presence of people at all hours of the day and night.

  10. Each community or cluster of communities should have a well defined edge, such as agricultural greenbelts or wildlife corridors, permanently protected from development.

  11. Streets, pedestrian paths and bike paths should contribute to a system of fully connected and interesting routes to all destinations. Their design should encourage pedestrian and bicycle use by being small and spatially defined by buildings, trees and lighting; and by discouraging high-speed traffic.

  12. Wherever possible, the natural terrain, drainage, and vegetation of the community should be preserved with superior examples contained within parks or greenbelts.

  13. The community design should help conserve resources and minimize waste.

  14. Communities should provide for the efficient use of water through the use of natural drainage, drought tolerant landscaping and recycling.

  15. The street orientation, the placement of buildings and the use of shading should contribute to the energy efficiency of the community.

Regional Principles

  1. The regional land use planning structure should be integrated within a larger transportation network built around transit rather than freeways.

  2. Regions should be bounded by and provide a continuous system of greenbelt/wildlife corridors to be determined by natural conditions.

  3. Regional institutions and services (government, stadiums, museums, etc.) should be located in the urban core.

  4. Materials and methods of construction should be specific to the region, exhibiting continuity of history and culture and compatibility with the climate to encourage the development of local character and community identity.

Implementation Principles

  1. The general plan should be updated to incorporate the above principles.

  2. Rather than allowing developer-initiated, piecemeal development, local governments should take charge of the planning process. General plans should designate where new growth, infill or redevelopment will be allowed to occur.

  3. Prior to any development, a specific plan should be prepared based on the planning principles. With the adoption of specific plans, complying projects could proceed with minimal delay.

  4. Plans should be developed through an open process and participants in the process should be provided visual models of all planning proposals.

Of course, in years of community work around development, I have never seen anything actually work like this.

The authors look at how this compares/ overlaps with New Urbanism and its principles (see the Congress for the New Urbanism for more…):

walkable neighborhoods, a range of housing choices, a mix of land uses, participatory planning, revitalization of urban neighborhoods (206)

They talk about some of the critiques. They come from wildly different directions…

  1. the public doesn’t want it
  2. it limits consumer choice — it’s a form of coercive social engineering
  3. can exacerbate traffic congestion by creating greater density
  4. smart growth projects are isolated enclaves, not integrated
  5. encourage gentrification (213)

Then go on to look at a public health approach to Smart Growth. It’s a very different perspective though concerned with all of the same things. They begin with constructing a community health assessment — paralleling the medical assessment. One method they believe has great promise is the Health impact Assessment, as a way to measure the health benefits from a Smart Growth approach. Nor is it surprising that many of the potential indicators would be the same as for sustainability — transit ridership, percentage of population living within ten minutes of a park, incidence of asthma, extent of recycling. (217) A few useful checklists exist already that could serve, one is the Built Environment Site Survey Checklist in London (this is news to me, this BESSC).(218)

I like how numerous things are coming together — concerns for the health of individuals and communities and neighbourhoods, issues of sustainability and the health of the land and environment. I think, again, there’s a lot more to think about in terms of equity. People’s own power in the process is always the first thing to go — if it ever was on the table. The cold hard facts of development and politics are not amenable to such things, so progress has been made where it helps certain kinds of development become more marketable. But criticism to come…

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Urban Sprawl and Public Health

Urban Sprawl and Public HealthUrban Sprawl and Public Health —  a great book! It was amazing to see urban planning and public health brought together in this way — a solid primer on both for each, along with a plea for professionals to start working together to fix this. Because sprawl is killing us.

I myself would throw in a soupçon of sociologists and geographers and community organizers to the health and planning mix as well, because what was missing? More analysis on the nature of development and how the drive for profit drives this urban form, more analysis on the struggle of everyday people to fight for and against some of these dynamics, and the ways in which race and land have long been linked (but there is more of this second aspect than in many another book). Still, despite these critiques, I confess that few things get me going the way that talking about the city and health in the same book do.

Health & Sprawl facts:

In the last 15 years, the US has developed 25% of all the land developed in the past 225 years of its official existence. (xii)

Between 1960 and 2000, average American’s yearly driving more than doubled — 4,000 to nearly 10,000 miles per years. “rush hour” spread over seven, not 4 and a half, average driver’s time spent stuck in traffic each year: 6 to 36 hours in Dallas, 1 to 28 hours in Minneapolis, 6 to 34 in Atlanta. (xiii)

On Sprawl

Sprawl — a term from William H. Whyte! Did I know that? He wrote an article for Fortune in January 1958, titled ‘Urban Sprawl’. There are a variety of definitions and measurements of sprawl, here they follow those that incorporate both land use and transportation as intrinsic. They focus on four main aspects — density, land use mix, automobile dependence and connectivity (or how destinations are linked through transportation systems (7). (5)

I particularly like how much they use illustrations, this is a good one:

"Source:
Source: Drawing by Duany Plater Zybek as shown in F. Spielberg, ‘The Traditional neighborhood Development: How will traffic Engineers Respond?’ ITE Journal 1989 (59) 17-18

I also liked the ‘transect’ — a look at the continuum between sprawl and compact neighbourhoods (16)

Transect 03-03-03" width="1572" height="530" class="size-full wp-image-7010" /> Source: Image courtesy of Duany Plater-Zybec and Company (2003) Transect 03-03-03
Source: Image courtesy of Duany Plater-Zybec and Company (2003) Transect 03-03-03

Chapter 2 looks at the origins of sprawl, and it is based almost in its entirety on Kenneth Jackson’s Crabgrass Frontier. So it summarizes the multiple factors that have lead to spraw, and it is a very long list. He heads it with the pull of the suburbs and the (European) cultural values Jackson believed underlay that pull — domesticity, privacy and isolation (28). In addition you have land ownership as a mark of wealth and status, alongside (partly driving perhaps, but I’m a cynic that this drove development rather than sales) a love of land itself and antipathy toward cities. (29) The Garden City movement feeds into this, embodied by Frederick Law Olmstead, along with the new technologies and construction methods and lots of cheap land (no mention of conquest here of course). There is a little here on the willingness of cities to spend taxes on providing infrastructure like roads and sewers — directly subsidising this kind of development as opposed to improving older neighbourhoods or public housing. The rise of the automobile and destruction of public transportation. The rise of zoning. The HOLC and the FHA, federal policy and money going towards new housing for whites (I do wish, though, that they had read Freund).

Still, I like the simplicity of their conclusions though:

Sprawl, as we know it today, appears deceptively chaotic. In fact, it is a highly ordered and predictable form of development. An edifice of public and private instruments erected over the past three-quaters of a century reinforces and extends sprawl. (42)

There is a little on financing here, and that real estate financing now works on an expectation of profits within 5-7 years — more built-in obsoleteness. I wish they had connected this to Harvey’s ‘spatial fix’ but that’s complex I guess. This is my field though, and this is a good summary.

Urban Health

Urban health is not my field, though I have a good deal of practical organising experience on the subject.

Frumkin et al compare the evolution of urban health with public health through ‘epidemiologic transition’ — and these titles really do inspire the SF writer side of my brain: The Age of Pestilence and Famine, The Age of Receding Pandemics, and where we are now: The Age of Degenerative and Man-Made Diseases. In cities, infectious diseases once dominated, but sanitary infrastructure ended that to a great extent. But industrialisation introduced pollution, and mental health and violence are not forgotten here, with growth in poverty, social dislocation and crime. (45)

From a public health perspective, the critical problems that grew as cities did were: garbage, commercial activity (tanning and other nasty things), sewage, water, air, and housing. (46)

An interesting aside:

In New York, Assemblyman Aaron Burr [founding father and profiteer] obtained a charter for the Manhattan Company, a private firm that was to hold a monopoly on piped water for the next quarter of a century. (51)

Privatised water is nothing new. Nor are the images from Jacob Riis in How the Other Half Lives. My family for example, hanging out with the other half in Pittsburgh, probably looked much like this, though they were never in this particular alley.

Bandit roost (59 Mulberry Street in New York City), Jacob Riis 1888
Bandit roost (59 Mulberry Street in New York City), Jacob Riis 1888

 The Results: A Plethora of Infections

Their heading, not mine. I had not read of the yellow fever epidemics that swept through Washington D.C. — as President Washington fled in 1793 leaving over 5,000 dead, or over ten percent of the city’s population. (55)

The book quotes a citizen group in Philly writing:

if the fever shall become an annual visitant, our cities must be abandoned, commerce will desert our coasts, and we, the citizens of this great metropolis, shall all of us, suffer much distress, and a great proportion of us be reduced to absolute ruin. (56)

it continues

Cholera, Typhoid…Cities in these early days were ‘incubators of infectious disease’ (57)

Now this is Pittsburgh just as my great-grandparents were arriving:

1890s, Pittsburgh, Pennsylvania, USA --- Smokestacks from factory in Pittsburgh, Pennsylvania, belch black smoke into the atmosphere, 1890s. --- Image by © Bettmann/CORBIS
1890s, Pittsburgh, Pennsylvania, USA — Smokestacks from factory in Pittsburgh, Pennsylvania, belch black smoke into the atmosphere, 1890s. — Image by © Bettmann/CORBIS

But slowly this would change…

During the nineteenth and twentieth centuries, as sanitary challenges were met and as industrial pollution was managed, the toxicity of cities–the factors that most threatened residents’ health and well-being and even helped drive migration out of the cities–came overwhelmingly to revolve around social circumstances. (61)

The heading for this section is ‘The Social Pathology of City Life’. (61)

during the nineteenth and twentieth centuries, as sanitary challenges were met and as industrial pollution was managed, the toxicity of cities–the factors that most threatened residents’ health and well-being and even helped drive migration out of the cities–came overwhelmingly to revolve around social circumstances. (61)

The urban crisis — it is interesting, perhaps a little troubling how the social is here linked with the epidemiological, but I am often troubled by the public health gaze at poverty. Foucault was too, so I’m in good company. The book here  notes the riots of the Red Summer of 1919 — yet it doesn’t distinguish these horrifying white killing sprees where literally hundreds of people were murdered with ‘riots’, what inhabitants themselves described as ‘uprisings’ in protest of police brutality and living condition in Watts in 1965, LA again in 1992 and etc (62).

It is interesting to consider the ‘urban health penalty’, however:

a complex of environmental conditions such as deteriorating housing, inadequate access to nutritional food, and scant medical care, and health consequences such as untreated hypertension, cardiocasvualr disease, intentionala dn unintentional injuries, and infectious diseases. (63)

Interesting to read of a 1990 article in New England Journal of Medicine showing that men in Harlem had lower life expectencies than in Bangladesh.* They write:

A literature of urban health arose, focusing on these conditions and how to provide health care to the victims. (63)

From here on to the nitty gritty.

Air Quality:

I like this chart:

IMG_5598

‘As the model illustrates, land use patterns affect each category of athropogenic emmissions–their location, their quantity, their dispersion in the air, and how people are exposed. (66)

And a summary of what air quality means for health:

Air pollution threatens human health in four principal ways. The two most important are by increasing mortality and by threatening respiratory health. In addition, air pollution can damage cardiovascular function and increase cancer risk. There is evidence for some other health effects as well. (80)

Physical Activity:

The ‘epidemic’ of obesity must be well known to anyone doing community work, or even who just reads the paper.

Being overweight is itself a well-established risk factor for a number of diseases. people who are overweight die at as much as 2.5 times the rate of non-obese people, and an estimated 300,000 Americans die preventable deaths each year as the result of being obese. (96)

So sprawl obviously has some share of this, creating environments where no one walks. Where it is dangerous to walk even if you wanted to, and there were somewhere to go. What features of the environment help people become more active?

Frank, Engelke and Schmid** identify three dimensions of the built environment…. land use patterns, design characteristics and transportation systems. (99)

Pikora et al*** expand on this, primarily in area of design — functional factors, safety factors, aesthetic factors and destination factors. So — a mix of different land uses, availability of sidewalks and footpaths, enjoyable scenery, the presence of other people in the space being physically active, safety.

Fucking rocket science, this is.

Injuries and Deaths from Traffic

Holy Jesus, this will make you never want to get in a car again. Over 40,000 people a year die by automobile. (110)

Water Quantity and Quality

So, you got your microbial contamination of water, your chemical contamination. You have your water scarcity. Sprawl affects all of these — thus the section titled ‘The Hydrology of Sprawl’. The rain falls, it percolates through foliage, roots and soil — cleansing itself as it does — to recharge groundwater and the water table. About half of us drink water from surface sources, and the other half from groundwater. My family drank from groundwater once, now we’re on a list, because it was contaminated. But that’s a longer story.

Forested areas are best at capturing and cleaning water, paved streets and rooftops, as you can imagine, fail completely. It all becomes chemical and pollutant-rich run-off. They give a view of what development’s effect is on this process:

Schematic view of water balance before and after development -- Center for Watershed Protection
Schematic view of water balance before and after development — Center for Watershed Protection

The stormwater runoff from suburban development contributes to microbial contamination as it ‘includes large loads of waste from pets and wildlife and nutrients from such sources as fertilizers’. Heavy runoff also carries sediment, these can protect dangerous bacteria like giardia as they sit in filters and drains. And then you have your further suburbs using wells and their own septic systems. The final way is unexpected — the continued growth of suburbs means the focus is on building new infrastructure, not repairing and cleaning out the old, which desperately need it. So our own pipes and things are poisoning us.

The chemical contamination is more obvious I think, all the toxic things we uses every day as well as those deposited by cars and exuded by factories all get swept into the water supply as well.

Mental Health

this is good to see here, I think it is left off of such analyses far too often. They remind us that sprawl is partly caused by a desire to get away from the city, into nature, into all that is good for mental health. Yet this is only one aspect of the suburbs — possibly offset by highways, sameness, box stores, speed, large scales, and just the amount of time people spend driving.

There is a whole of information on just how bad for us driving is. How it increases stress, makes us angrier. Studies on road rage. All of these things could, most likely do, contribute to morbidity.

Social Capital

This comes from community. They define such a sense of community as a

“feeling that members have of belonging, a feeling that members matter to one another and to the group, and a shared faith that members’ needs will be met through their commitment to be together.”**** There are four aspects of this sense of community: membership, influence, integration and fulfillment of needs, and shared emotional connection. (161)

They look at the many ways community psychologists, human ecologists, and sociologists have talked about community and social capital, but much of it is based on Robert Putnam’s Bowling Alone, so I won’t go on too much more here except for the ways it affects health. I’ll be dealing with Putnam too. Everyone quotes him.

Research has focused on two broad aspects of the social environment: structural features and social support. Structurally, people look at the density of relationships and extent of social networks. Social support is described as the the amount of emotional support (and other kinds?) in times of need (166. In a nutshell: People with strong social networks live longer. Lots of studies confirm it (you can see the Marmot Review on the UK). (166) The same correlations hold true for social capital.

Sprawl, on the other hand, tends to to diminish both networks and capital in several ways:

  1. Cars have much to do with this, the amount of time people spend driving restricts free time for civic engagement.
  2. sprawl ‘reduces opportunities for spontaneous, informal social interactions’ (173)
  3. ‘sprawl privatizes the public realm’, people who spend all their time at home don’t value public space, green space, suburban voters almost always vote to limit government programs with social goals or for public transportation
  4. sprawl divides people into homogenous communities.
  5. sprawl disrupts continuity of life as people age — can’t move into smaller house in the same neighbourhood (173)
  6. 1998 report from the Transit cooperative Research program found that ‘sprawl weakens households’ connection both to their immediate neighbors and to the larger metropolitan community. (174)

But it turns out that some sprawl better than others — the built environment and design can affects this, so there is some hope. But this first post is on all that is wrong, the second on what can be made right…

Health Concerns of Special Populations

I do like that there is focused attention on how sprawl impacts different groups, acknowledging that the costs of it are not even. There is a long list…Given that women are usually doing most of daily chores and chauffeuring of kids, the burden falls disproportionately upon them.

Children breath more rapidly, have narrower airways — thus pollution has much more impact on them than on adults. The lack of physical activity affects them more — and yet when they are physically active in polluted areas, it is more dangerous for them. Part of childhood is exploration of the world and the self away from parents — yet we have built spaces where that is not safe, impacting the mental health and development of kids. They are isolated, and don’t have the wealth of networks and adults watching out for them that a health community might have.

The elderly, too, are severely impacted. Communities that aren’t walkable require cars — so people drive long past the time they should not. Elders are isolated, unable to exercise, unable to have meaningful connections that improve their health and quality of life. This is often also true for those who are disabled. How dare we create cities without sidewalks.

Then, of course, there are the poor and people of colour. A reprise here for HOLC and FHA regulations, the racism that confined people into inner cities (I don’t think they quite realise how prevalent this continues to be). The steady concentration of poverty and its related health impacts in areas of higher pollution. The disparities of race in class so visible in health and morbidity statistics.

The connections are multiple and strongly evidenced. Enraging really. I like that they don’t stop there, but include a final chapter on possibilities for changing our cities and our future. That will follow in the next post.

*McCord C., Freeman, H. Excess mortality in Harlem. New England Journal of Medicine 1990; 322: 173-179.

**Frank, Engelke and Schmid (2003) Health and Community Design: How Urban Form Impacts Physical Activity, Washington D.C.: Island Press.

*** Pikora, T et al (2003) Developing a framework for assessment of the environmental determinants of walking and cycling. Social Science and Medicine 56: 1693-1703

**** McMilland and Chavis
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Root Shock pt 2 — Struggle and the Aesthetics of Equity

Root Shock - Mindy Thompson FullilovePsychiatrist Mindy Fullilove’s Root Shock doesn’t just explore the costs of displacement to the consciousness of the individual and the collective, but also looks at struggle on multiple levels. First, though, lets just revisit her framing of the issue:

When all the fancy rhetoric about “blight” is stripped away, American urban renewal was a response to the question, “The poor are always with us, but do we have to see them every day?” The problem the planners tackled was not how to undo poverty, but how to hide the poor. Urban renewal was designed to segment the city that barriers of highways and monumental buildings protected the rich from the sight of the poor, and enclosed the wealthy center away from the poor margin.(197)

I also like this fundamental insight:

In the peculiar calculus of American racism…white people must occupy whole parts, like a whole row of bus seats or a whole neighborhood. As soon as any black people enter, the whole is spoiled, and the white people must either eject the black people…or move away themselves. (225)

The most basic means of struggle against such a calculus is that as an individual or group, in the form of political direct action. She talks about what fighting back means to people, quotes testimony from trials:

Gladys Moore on the Montgomery Bus Boycott: “Well, after so many things happened. Wasn’t no man started it. We all started it overnight. (emphasis added) (40)

Jo Ann Robinson, in her memoirs: “The one day of protest against the white man’s traditional policy of white supremacy had created a new person in the Negro. The new spirit, the new feeling did something to the blacks individually and collectively, and each liked the feeling. There was no turning back! There was only one way out–the buses must be changed!” (41)

She also talks about the healing process that occurs through collective struggle, which is nice to hear from a medical professional:

As a public health psychiatrist, I believe that healing a group’s psyche occurs through a collective process that requires organizing ways in which people come together to learn facts, share ideas, raise questions, and search for solutions. (180)

Near the end of the book she lays out a series of workshops done with community members. The first used an idea she called ‘The Community burn Index’, used to measure the damage to the neighbourhood lot by lot, charted through a community mapping exercise where small groups walked street by street telling stories and really seeing their streets and homes. I quite loved what this revealed:

I learned something about the difference between interiority and exteriority when it comes to what we see. People who are insiders to a place stop seeing it. It is a hand part of human consciousness that many things–including the scenery we look at every day–slip our of awareness in to the vast pool of rote activities and knowledge.

People who are outsiders to a place see it as a landscape. they are inhibited from seeing what they’re really seeing, but in their case it’s not because it’s new. Rather, we have another handy mental device for decoding places we’ve never been to before, and that is stereotyping… Oddly enough, neither the inside nor the outsider has the foggiest idea what he is look at. (185)

It is coming together to really look, to see things in the moment as they are, to tell stories, to talk to each other, that they helped each other really see what was there, what was no longer there.

That’s powerful, no?

They repeated this exercise with people from all over Pittsburgh, trying to build connections not just between residents and their built environment, but between people from other neighbourhoods and this particular neighbourhood so long cut off from the city. Through the eyes of a French planner and architect, they realise that this is a neighbourhood that once had multiple entries and exits and paths down the hill to the river, and all of them had gone, sealing them off from the rest of the city.

It is through discussions with this same architect, Michel Cantal-Dupart, that Fullilove proposes a new framework for analysing and resolving issues created by development. She calls it the aesthetics of equity, and it holds some interesting ideas I think. In summary:

Principle One: Respect the Common Life the Way you Would an Individual Life (199)

There is always a common life, whether or not you can see it right away. My own aside — people in power never see it.

Principle Two: Treasure the Buildings History Has Given Us (199)

If only planners had ever done that…instead we work with what they have left us, and I think this is key:

The solution to the “many centers” problem lies in improving the connections among them. The passerby must be able to figure out how to move among the jumble of squares. We need images that compel transition, promote flow, and permit movement from one place to another. We need a permeable city, safe not because of its walls, but because of the engagement of its citizens, each and every one a guardian of the public piece/peace. (204)

Here Fullilove edges towards all the wonderful literature studying how buildings and planning create environments that foster and build community.

Principle Three: Break the Cycle of Disinvestment (204)

I suppose here is where my study of political economy makes me a little skeptical that this could happen without one hell of a fight that is more transformative than anything we’ve seen before. But I write too much about that elsewhere. Still, it is fundamental to these dynamics, and needs to be understood just as much as everything else here.

Principle Four: Freedom of Movement (205)

Hell yes. This has never really existed in the U.S. for non-whites. But there’s a funny section here on the massive gardens of André Le Nôtre built for French aristocrats and the Sun King himself. I feel strongly about such gardens that use perspective to show power and wealth and the subjection of nature, so it’s interesting to be challenged here with a sentence that says 

Perspective creates both the intimacy of “here” and the wonder of “there”. It allows rest and dwelling, but it also encourgaes exploration and travel… Perspective is, at heart, a democratic tool, because it is a linking tool. (208)

I think Gordon Cullen explores this quite beautifully in the townscape in ways that show just how much about power and wealth those damn gardens really are. But point taken in the abstract. I think Cantal has some odd views being passed along here, as Haussman is praised a little further along for his vistas and opening up of the city, and that just makes me a little sad without acknowledging the massive displacement, the purpose of making the poor easier to control and send them to the peripheries.

Still, I quite like these four principles. Just as I do the idea that people should be able to take city spaces and make it their own.

I also like the thought she ends with:

We are somewhere on the dwelling/journey spiral. We have all been forced from home but non of us has yet reached safety. We might choose to continue to proceed in blindness. But we might also recognize that we can use the journey to create the arrival of our dreams in the community of all of us.

Let us listen to the bell; it tolls for us. It’s time to go home. (239)

 

 

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Root Shock pt 1 — Urban Renewal and Public Health

Root Shock - Mindy Thompson FulliloveThis is one of the few books that really tries to come to grips with the deep psychological trauma caused by mass displacement — what it calls Root Shock. It does so through the prism of urban renewal and reminds us of the scale of it. The program ran  from 1949 to 1973, and during this time the U.S. government bulldozed 2,500 neighborhoods in 993 cities, dispossessing an estimated million people. They were supposed to be slum clearances, they were supposed to create space for new housing. Few of these clearances did, and we are still coming to grips with what was lost. But there is a bitter truth behind the switch from ‘urban’ to ‘Negro’ removal — it is the Black community that lost the most and that continues to be most impacted by it all.

What was it, then, that was lost?

…the collective loss. It was the loss of a massive web of connections–a way of being–that had been destroyed by urban renewal; it was as if thousands of people who seemed to be with me in sunlight, were at some deeper level of their being wandering lost in a dense fog, unable to find one another for the rest of their lives. It was a chorus of voices that rose in my head, with the cry, “We have lost one another.” (4)

I like this understanding of it. I also quite love that despite a clinician trying to deepen our understanding of the psychological impacts, she maintains a larger understanding of just what is happening.

This process taught me a new respect for the story of upheaval. It is hard to hear, because it is a story filled with a  large, multivoiced pain. it is not a pain that should be pigeonholed in a diagnostic category, but rather understood as a communication about human endurance in the face of bitter defeat. (5)

And you know I love the spatial awareness that has to be part of this, because it is a physical loss of building, home, neighbourhood, as much as a loss of connection.

Buildings and neighborhoods and nations are insinuated into us by life; we are not, as we like to think, independent of them. (10-11)

So how does Fullilove define Root Shock?

Root shock is the traumatic stress reaction to the destruction of all or part of one’s emotional ecosystem. It has important parallels to the physiological shock experience by a person who, as a result of injury, suddenly loses massive amounts of fluids. Such a blow threatens the whole body’s ability to function…. Just as the body has a system to maintain its internal balance, so, too, the individual has a way to maintain the external balance between himself and the world. This way of moving in the environment…. (11)

It is not something that is experienced right away and then disappears.

The experience of root shock–like the aftermath of a severe burn–does not end with emergency treatment, but will stay with the individual for a lifetime. In fact, the injury from root shock may be even more enduring than a burn, as it can affect generations and generations of people.

Root shock, at the level of the individual, is a profound emotional upheaval that destroys the working model of the world that had existed in the individual’s head. (14)

This book is interladen with quotes and stories from people Fullilove worked with, she cares like I do to let people speak for themselves about their experience. She quotes Carlos Peterson, on the bulldozing of his neighbourhood:

‘My impression was that we were like a bunch of nomads always fleeing, that was the feeling I had.” (13)

There is Sala Uddin, who remembered urban renewal first with approval — the new homes they were getting, then:

Critiquing his own earlier enthusiasm, he pointed out to me, “We didn’t know what impact the amputation of the lower half of our body would have on the rest of our body until you look back twenty years later, and the rest of your body is really ill because of that amputation.

The sense of fragmentation is a new experience that we can now sense, that we didn’t sense then. We were all in the same location before. Now we are scattered literally to the four corners of the city, and we are not only politically weak, we are not a political entity. We are also culturally weak. And I think that has something to do with the easiness of hurting each other. How easy it is to hurt each other, because we are not that close anymore. We are not family anymore. (175)

Because she is able to listen, she is able to describe the ways that people are connected both to buildings, but also to each other. I love how from multiple angles, the human connections to the earth, to the built environment and to each other always emerge as key to lives well-lived, whether looking at permaculture or public space or psychology:

This lesson of interconnectedness is as hard to learn as differential calculus or quantum mechanics. the principle is simple: we–that is to say, all people–live in an emotional ecosystem that attaches us yo the environment, not just as our individual selves, but as being caught in a single, universal net of consciousness anchored in small niches we call neighborhoods or hamlets or villages. Because of the interconnectedness of the net, if your place is destroyed today, I will feel it hereafter. (17)

This brings a new look at Jane Jacob‘s street ballet, where

you are observing the degree to which people can adapt to different settings, and not just adapt, but attach, connect. They are connecting not to the negatives or even the positives of the setting, but to their own mastery of the local players and their play. (19)

I am quite intrigued by this idea:

Instead, the geography created by dispersal-in-segregation created a group of islands of black life. “Archipelago” is the official geographic term for a group of islands. Black America is an archipelago state, a many-island nation within the American nation. The Creation of the archipelago nation had two consequences for African Americans. The first is that the ghettos became centers of black life; the second is that the walls of the ghetto, like other symbols of segregation, became objects of hatred. In this ambivalent, love/hate relationship, it was impossible to chose to dwell. Yet people did choose to make life as vibrant and happy as they possibly could. (27)

This feels particularly true of earlier periods when the colour lines were hard and fast and patrolled by white mobs and white gangs and the use of violence. When green books were necessary when travelling to know where to stay, what to eat safe from the oceans of white hatred (too far? Not in terms of the hatred, but maybe in terms of metaphor…) When the ghetto walls were high and strong and each brick legally protected, which is part of the story and the trauma of urban renewal’s root shock. For so long people faced the choice: to fight to improve the ghetto or the fight to leave it. Regardless, she captures something of what the ghetto cost the city as a whole:

Segregation in a city inhibits the free interaction among citizens and invariably leads to a brutality and inequality, which themselves are antithetical to urbanity. When segregation disappears, freedom of movement becomes possible. that does not necessarily mean that people will want to leave the place where they have lived. The ghetto ceases to be a ghetto, it is true, but it does not stop being a neighborhood of history. Postsegregation, the African-American ghetto would have been a sight for imaginative re-creation , much like the ghetto in Rome. (45)

She writes later on:

The divided city is a subjugated city. (164)

The tragedy always was this inisght, again from Jane Jacobs  (as summarised by Fullilove):

A slum would endure if residents left as quickly as they could. A neighborhood could transform itself, if people wanted to stay. It was the investment of time, money  and love that would make the difference. (44)

That was almost never allowed to happen. Instead neighbourhoods were bulldozed — and again there is the comparison to rubble left by war, similar to Dybek, to Gbadamosi:

Indeed, in looking at American urban renewal projects I am reminded more of wide-area bombing–the largely abandoned World War II tactic of bombing major parts of cities as we did in Wurzeburg, Germany and Hiroshima, Japan–than of elegant city design. (70)

It was done in the most destructive way possible:

Even though the basis for compensation was gradually extended, the payments continued to be linked to individual property rights. Collective assets — the social capital created by a long-standing  community–were not considered in the assessment of property values. (79)

There is not enough on why I think, which limits the section thinking through what we can do to stop it. But there is this quote from Reginal Shereef, who studies the effects of urban renewal on African Americans in Roanoke:

“But the reality of urban renewal was that cities wanted to improve their tax base. And that is my interest. I have always looked at the intersections between public policy and economics. And what happened in Roanoke was neighborhoods was torn down so that commercial developers could develop prperties and sell it to private interests…” (98)

Part 2 looks at some of the positive ways to think of community, ways that we can work to preserve and improve our neighourhoods. But I’ll end this with one of the lovelier expressions of what home means to people, this from resident Dolores Rubillo:

“People know, you know where you are–” and, leaning in to me added, “you are safe in the dark.” (127)

 

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Full Society, Healthy Lives: Thoughts on the Marmot Review

fair-society-healthy-lives-full-report-1In my mind there are two quotes that really encapsulate what the Marmot Review is. The first is the epigraph, and for me it was breathtaking to find it here:

Rise up with me against the organisation of misery.
–Pablo Neruda

The second? A clear outline of where exactly the researchers began:

The starting point for this Review is that health inequalities that are preventable by reasonable means are unfair. Putting them right is a matter of social justice. A debate about how to close the health gap has to be a debate about what sort of society people want.

Surely it is time we started there and moved forward. It does note (and I chuckled at this, I’m not sure why):

It is sometimes difficult for many people to accept that serious and persistent health inequalities exist in England.

By ‘many people’ I assume they mean the happy middle and upper classes with reasonable health. But on the other side of the class (and race and nationality and gender and sexuality) lines, it is no real surprise that the WHO (World Health Organisation) Commission on Social Determinants of Health should have ‘surveyed the world scene and concluded that “social injustice is killing on a grand scale.”‘ Is that the kind of world we support?

Most would answer no. I also think most would agree with this:

Economic growth is not the most important measure of our country’s success. The fair distribution of health, well-being and
sustainability are important social goals. Tackling social inequalities in health and tackling climate change must go together.

I like too this call to the health profession to begin to engage with the fact that our socioeceonomic position is more determinative of our health than any prescription or therapy that they can give  — as well as to policymakers and politicians to lower our NHS bills by increasing equality and opportunity in our society:

People with higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health. The two are linked: the more favoured people are, socially and economically, the better their health. This link between social conditions and health is not a footnote to the ‘real’ concerns with health – health care and unhealthy behaviours – it should become the main focus.

The two main policy goals they propose are these:

  • To create an enabling society that maximises individual and community potential

  • To ensure social justice, health and sustainability are at the heart of all policies.

Wouldn’t that be great? These break down into 6 more concrete policy suggestions (and these are made more and more concrete for implementation at the end of the report):

  • Give every child the best start in life

  • Enable all children young people and adults to maximise their capabilities and have control over their lives

  • Create fair employment and good work for all

  • Ensure healthy standard of living for all

  • Create and develop healthy and sustainable places and communities

  • Strengthen the role and impact of ill health prevention

The evidence they marshal in support of these positions is so impressive, beginning with the weight of these first two graphs as shown below. The first represents over ten years difference between the wealthiest and the poorest in how long they may statistically expect to live. Over ten years. More sobering, perhaps, is the number of years available to us to live  in fullness of life and health, without disability. For the very poorest, they can expect age and ill-health related disabilities in their early fifties — it breaks my heart.

For the heartless, imagine the fucking economic cost of that.

Direct NHS healthcare costs in England associated with treating the consequences of inequality amount to £5.5 billion per year for treating acute illness and mental illness and prescriptions.228 These activities represent approximately one third of the NHS budget. In consequence, it is likely that the full impact of health inequalities on direct healthcare costs is considerably greater than this.

The review also notes:

As further illustration, we have drawn on Figure1 a line at 68 years – the pensionable age to which England is moving. With the levels of disability shown, more than three-quarters of the population do not have disability-free life expectancy as far as the age of 68. If society wishes to have a healthy population, working until 68 years, it is essential to take action to both raise the general level of health and flatten the social gradient.

Ah, to be 68 and working for the bosses while disabled, I can’t wait.

fair-society-healthy-lives-full-report-18

The power of the second graph is the difference in mortality between regions. This also breaks my heart. Surely the point of a nation and a national government is to aim for some level of parity in opportunity and life.

The graphic below is  crazy too, it shows the effect of wealth and environment on intelligence (or at least, the ability to show intelligence through testing). This is about class and education, which of course intersects with health but also with our ability to become the person we want to be, live the lives we are capable of living. The review explains:

As Figure 6 shows, children who have low cognitive scores at 22 months of age but who grow up in families of high socioeconomic position improve their relative scores as they approach the age of 10. The relative position of children with high scores at 22 months, but who grow up in families of low socioeconomic position, worsens as they approach age 10.

fair-society-healthy-lives-full-report-24Are you ready to change the world yet?

From education you move into work — and poor people’s work is killing them. Worse, though, is that the lack of work is also killing them.

Getting people into work is therefore of critical importance for reducing health inequalities. However, jobs need to be sustainable and offer a minimum level of quality, to include not only a decent living wage, but also opportunities for in-work development, the flexibility to enable people to balance work and family life, and protection from adverse working conditions that can damage health.

Another graphic to blow your mind — the direct link between employment and mortality:

The dramatic increase in unemployment in the United Kingdom during the early 1980s stimulated research on the link between unemployment and health. Figure 8 shows the social gradient in the subsequent mortality of those that experienced unemployment in the early 1980s. For each occupational class, the unemployed have higher mortality than the employed.

fair-society-healthy-lives-full-report-28

It’s community that I’m most interested in, perhaps because I think it is a way to mitigate all of these things while we fight to make the world more fair, and because everything goes to show that the closer and more supportive a community is, the healthier its members are. Building that kind of community where I live and work feels like something I can actually do to make a difference (that and join a union). But thinking geographically, the physical neighbourhood we live in also has a huge impact on our lives, both in terms of quality and length:

In the poorest neighbourhoods of England, life expectancy is 67, similar to the national average in Egypt or Thailand, and lower than the average in Ecuador, China and Belize, all countries that have a lower Gross Domestic Product and do not have a national health service.

Now ain’t that something? Here’s another set of bullet points on environment and health:

  • The conditions in which people are born, grow, live, work, and age are responsible for health inequalities.

  • Early childhood, in particular, impacts on health and disadvantage throughout life.

  • The cumulative effects of hazards and disadvantage through life produce a finely graded social patterning of disease and ill health.

  • Negative health outcomes are linked to the stress people experience and the levels of control people have over their lives and this stress and control is socially graded.

  • Mental well-being has a profound role in shaping physical health and contributing to life chances, as well as being important to individuals and as a societal measure.

This evokes the complexities shaping these things a little better:

the distribution of health and well-being needs to be understood in relation to a range of factors that interact in complex ways. These factors include: material circumstances, for example whether you live in a decent house with enough money to live healthily; social cohesion, for example whether you live in a safe neighbourhood without fear of crime; psychosocial factors, for example whether you have good support from family and friends; behaviours, for example whether you smoke, eat healthily or take exercise; and biological factors, for example whether you have a history of particular illnesses in your family. In turn, these factors are influenced by social position, itself shaped by education, occupation, income, gender, ethnicity and race. All these influences are affected by the socio-political and cultural and social context in which they sit.

These are many of the things that determine where we live, and the kinds of support we can expect. Once our place of residence is decided, the other health issues kick in. So much of this is really about the physical hazards that exist in poorer neighbourhoods (and there is more work on this than is shown here), but also the mental hazards of poverty, and the lack of power and control that comes with it. The lack therefore, of even the possibility of true wellness.

There is substantial evidence of a social gradient in the quality of neighbourhoods. Poorer people are more likely to live in more deprived neighbourhoods. The more deprived the neighbourhood, the more likely it is to have social and environmental characteristics presenting risks to health. These include poor housing, higher rates of crime, poorer air quality, a lack of green spaces and places for children to play and more risks to safety from traffic. In the 30 years between 1970 and 2000 Britain saw a substantial increase in the geographical concentration and segregation of poverty and wealth. Since 2000 there seems to have been little progress in reducing this. Urban clustering of poverty has increased…wealthy households have become concentrated on the outskirts and areas surrounding major cities. During the same period, major restructuring of the British economy has led to the loss of manufacturing and traditional industries, with high levels of economic inactivity becoming concentrated in particular localities and neighbourhoods.

It is this segregation of poverty and wealth that is also the problem, a writing off of estate and neighbourhoods and what looks like the whole Northeast of the country.

Since reading Appleyard’s Liveable Streets, I’ve also been thinking a lot about how community is destroyed by streets and cars and traffic, and it is the poorest that suffer most — this graph really brings it home:

fair-society-healthy-lives-full-report-82

I do like the fact that they point out that these are not just issues for the poor, however, although they clearly suffer most and resources should be targeted accordingly. They write

…everyone beneath the very best-off experiences some effect of
health inequalities. If the focus were only on those most in need and social action were successful in improving their plight, what about those just above the bottom or at the median, who have worse health than those above them? All must be included in actions to create a fairer society.

This also means health providers and community workers actually working together closely in taking on some of these problems.

Community engagement on a systematic basis is an essential element in partnership working for addressing health inequalities. Without this, reducing health inequalities will not be possible.

This approach requires mapping community assets, identifying barriers to participation and influencing and building community capacity through systematic and sustained community development.

They look at different ways this could happen. One is through focusing on building stronger social support networks to fight the high levels of stress, isolation and depression found in communities facing high level of deprivation, which can lead to ‘increased risk of premature death’. They note the effectiveness both of social networks and participation in improving mental health generally, but also the importance of including communities and individuals in the design of interventions.

They give some recommendations on how to go about things, which in the end lead to local individuals and communities being able to have power over their health, their lives, and the neighbourhoods they live in.

    1. First, identifying population needs better quality information from communities. In theory this can lead to health improvements and reduced health inequalities through an increased uptake of more effective services, particularly preventative services, and/or more effective interventions.

    2. Second, improving governance and guardianship and promoting and supporting communities to participate in directing and controlling local services and/or interventions. This will help to improve the appropriateness and accessibility of services and interventions, increase uptake and effectiveness and influence health outcomes.

    3. A third way to reduce social isolation is to develop social capital by enhancing community empowerment. This helps to develop relationships of trust, reciprocity and exchange within communities, strengthening social capital.

    4. Lastly, increasing control and community empowerment may result in communities acting to change their social, material and political environments.

       

Somethings about what not to do (but what gets done all the damn time), because the point is empowering people which in itself creates better health:

To achieve this goal community engagement practices need to move beyond what are often routine, brief consultations, to involving individuals in partnerships to define problems and develop local solutions to address those problems.

Which involves

Building active and sustainable communities based on principles of social justice. This is about changing power structures to remove barriers that prevent people from participating in the issues that affect their lives.

Promoting this approach sets a new task for political, civic and public service leadership in creating the conditions which enable individuals and communities to take control of their own lives, and in developing and sustaining a wider range of capabilities across the life course.

I like this idea of the life course, it is not one of the ways in which community organisers or planners tend to think, but makes perfect sense when looking at how negative impacts — in health and everything else — accumulate over our lifetimes and those of our children. I’ve also run into a few people, women for the most part, really trying to think about this in architecture and planning, how people age through housing and community, how their needs and desires change.

I also like how this review ties health in to climate change. They never say out right that all of this is academic in the face of massive environmental catastrophe, but it was in my mind at least. They do relate community and social health to increased green spaces, more walking, healthier work, more use of public transport  and etc which all contribute to making everything more sustainable.

I had a few quibbles of course. Any review of this kind, looking at the big picture, will have the problem I think of speaking in big categories, lumping categories of people in together as though they are all one thing. Sometimes I was a bit troubled as it threw around generalisations — such as the study of kids receiving free meals at schools and how terrible their outcomes were by whether they were irish, black, gypsy/ traveller/ roma children. That shit bothers me. I was one of those kids. Every now and then the language starts to shut our potential off, to overcome, to think bigger, to improve our lives and others like us. To set poor kids apart as if they can’t have a hand in changing this.

That might just be me on my high horse, some of this came a little close to home. It’s always a fine balance though, between recognising the power of structural injustices and constraints, and respecting the abilities of those who most suffer under them.

Even as it did make some of the distinctions above, and never forgot to mention the complexities of race and class in this picture, it also failed to look at them in any real way. Gender too is absent. It does, however, provide a good foundation for exploring these equity and justice issues further.

There’s also some technical language that highlights the bureaucratisation of the field. I quote you as an example ‘middle-level Super Output Areas (MSOAs)’ which I suppose are required for policy discussions to change public health practices as they are existing realities, yet they make you want to hit the person who coined them.

And for those in the non-profit world (and increasingly other areas) always in search of how to stay funded, there are a couple of nice passages on some things I wish all funders and policy makers could understand. Principally that things take time, projects need to grow organically and be tailored to different people and institutions in different areas, relationships and trust only come after years, not days or weeks.

Reviews often look for new interventions, particular policies that may help turn the corner or make significant impact in improving service quality. However, a stream of new initiatives may not achieve as much as consistent and concerted action across a range of policy areas. A social determinants approach to health inequalities highlights how it is the intersection between different domains that is critical – health and work, health and housing and planning, health and early years education. Success is more likely to come from the cumulative impact from a range of complementary programmes than from any one individual programme and through more effective, coherent delivery systems and accountability mechanisms….. achieving reductions in health inequalities requires coherent, concerted, long-term, cross-cutting policies, backed by sufficient investment.

There are also some practical points on how funding is killing smaller organisations, despite the fact that they are highly committed, flexible and most integrated into the communities they serve, making them most likely to be the most effective.

There is increasing concern that the current commissioning environment disadvantages the third sector generally and may even threaten the survival of smaller voluntary organisations. The range of factors includes:

  • The inability of smaller organisations to marshal the resources, including the time, skills and knowledge, to effectively compete for tenders

  • Commissioning practices favouring larger organisations and the statutory sector, for example, clustering services to be put out to tender in a single contract can lead to smaller and niche providers being squeezed out

  • Short-term contracts with insufficient time for development and consequences for staff recruitment and retention

  • The growing requirement for contracts to be delivered on tighter funding, leaving little scope for developmental work and innovation.

Recipe for disaster really, and the unhelpful bureaucratization of exactly the kind of community work that bureaucratization strangles dead and can never on its own get right.

Anyway, this report is mostly wonderful. You can download it here.

A Journal of the Plague Year

A Journal of the Plague YearDaniel Defoe ([1722] 2003)

A Journal of the Plague Year is grim, strangely gripping almost in spite of its author.

I had to try and remember that this is so early, among the earliest of the many claims of earliest novels — that’s hard enough. Written decades after the events it is describing, it’s still questioned how much of it is based on Daniel Defoe’s uncle’s diary (he himself was 5 at the time he describes in such detail), how much is historical research, how much is ‘novel’. It’s strangely removed yet at the same time close enough to be fairly terrifying.

Many claim it as part of the psychogeography tradition, an early example of a literary mapping of London, and I confess that is what I liked the most. The street by street, parish by parish descriptions, the sense of all London reading the death lists, waiting, watching the plague move from West to East and South but all the while hoping it wouldn’t reach them. Getting some sense of what these times were like, how they were lived so far removed from imagination and Hollywood’s occasional depictions. It’s hard to believe that it all started only a short distance from where I work every day in Holborn.

I haven’t read much beyond wikipedia and short descriptions, but what bothered me most was trying to decide how much irony is in this, how much is written straight faced. I just couldn’t tell. From the point of view of someone who doesn’t identify with the rich but with the poor, it is fairly staggering. He rails against the thievery, the lengths to which the well-off had to go when fleeing the city to protect their property–there is so much here about protecting property. So damn much. Yet he himself lists the multiple professions, the thousands that lost all work and hope of sustenance when the plague hit London. The many families who fled the cities, firing their servants and turning them out of their homes penniless and with nowhere to go.

He writes at one point of the plague as a kind of deliverance, how it:

carried off in that time thirty or forty thousand of these very poor people which, had they been left, would certainly have been an insufferable burden by their poverty; that is to say, the whole city could not have supported the expense of them, or have provided food for them; and they would in time have even been driven to the necessity of plundering either the city itself or the country adjacent, to have subsisted themselves…

In fact, it is extremely noticeable that all of the much vaunted charity of the city and ‘gentlemen’ of the country is primarily a measure to stop mass starvation resulting in rebellion and theft. Personally, I was angry enough at it that I was hoping for a little more pillage, for some distribution of the high life in this time of horror, especially as he describes the frightful conditions under which people lived. Their desperation is visible in the number of people willing to risk their lives for the small pay offered them to nurse the sick and watch at their doors and dig the graves and collect and bury the dead.

While praising London’s government for running the city well through it all, Defoe blames the poor for spreading the plague, for not remaining shut up in their houses like the wealthy, waiting out the infection:

But it was impossible to beat anything into the heads of the poor. They went on with the usual impetuosity of their tempers, full of outcries and lamentations when taken, but madly careless of themselves, foolhardy and obstinate, while they were well. Where they could get employment they pushed into any kind of business, the most dangerous and liable to infection…

As though people seek out such employment when they don’t need to eat. There is also a curious interlude when he reproaches some men getting drunk in a pub and laughing at those praying and grieving. He tells them to repent, to learn from his own behaviour, and tells them he is saved by God…As I say, almost over the top enough that it could be stab at some critique of the religious and the rich, but left me with the feeling that it’s probably not, or not critical enough. Though it has contradictory opinions in it to fill another book sorting them all out.

Thank god I live now.

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